About Infirmary Integrated
Infirmary Integrated is free and open-source software developed to advance healthcare education for medical and nursing professionals and students. Developed as in-depth, accurate, and accessible educational tools, Infirmary Integrated can meet the needs of clinical simulators in emergency, critical care, obstetric, and many other medical and nursing specialties.
Infirmary Integrated is a free simulator for healthcare devices to aide in medical and nursing education. By simulating medical devices such as a defibrillator or external fetal monitor, students can practice reading tracings, interpreting waveforms, and starting interventions. Educators can use Infirmary Integrated to enhance simulations in a lifelike environment similar to patient care areas, allowing educators to simulate patient presentations and hemodynamic states ranging from simple simulations to extremely complex scenarios. Infirmary Integrated is developed to be clinically accurate and contain relevant content. Additionally, Infirmary Integrated is free and open source software in order to be accessible for healthcare professionals around the world.
Features
Infirmary Integrated currently functions as a simulator for the following healthcare devices:
- Cardiac monitor
- Defibrillator
- 12-lead electrocardiograph (ECG)
- Intra-aortic balloon pump (IABP)
- External fetal monitor, cardiotocograph (EFM/CTG)
- Electronic Health Record (EHR): Demographics & Clinical Notes
- Electronic Health Record (EHR): Medication administration record (MAR)
Main features included in Infirmary Integrated include:
- Realistic waveforms draw according to multiple factors, accounting for:
- Atrial and/or ventricular contractions
- Aberrant/ectopic beats and resulting decreased pulsatility
- Intrathoracic pressure, depending on mechanical or spontaneous ventilation
- Able to pause devices to better analyze waveforms or create screenshots
- Visual and audio alarms realistically simulate devices for enhanced clinical realism
- Advanced modeling algorithms allow for on-the-fly changes to hemodynamic parameters with a smooth and responsive simulation
- Able to create and play scenarios where the patient’s condition changes and progresses
- Students can react to changing patient conditions with pre-made scenario options
- Instructors can guide students through simple or complex pre-made patient presentations and disease progressions
- Able to mirror patient data across multiple computers
- A teacher can run a simulation and automatically broadcast it across the internet
- Students can subscribe to a broadcasted simulation and their screens will automatically synchronize
- Broadcasting is seamlessly and securely processed through Infirmary Integrated’s server
- Able to save simulations to files (.ii extension) that can distributed or saved
- Device information and options are also saved in simulation files
- Multiple color schemes can be selected for each device simulator
- “Dark” mode for realistic green-on-black ECG and monitor tracings
- “Light” mode for high-contrast uses such as on an overhead projector
- Some devices allow for “Grid” mode, replicating an ECG traced on gridded ECG paper
And Infirmary Integrated can simulate hemodynamic and other readings including:
- Heart rate (HR)
- Temperature (T)
- Blood pressure (NIBP non-invasive and invasive ABP via arterial line)
- Respiratory rate (RR)
- Pulse oximetry (SpO2, pulse oximeter plethysmograph)
- End-tidal capnography (ETCO2)
- Central venous pressure (CVP)
- Pulmonary artery pressures and waveforms (Swan-Ganz catheter pressures)
- Including all pressures and waveforms to simulate catheter placement and wedging
- Cardiac Output (CO)
- Intracranial pressure (ICP) factoring compliance in the waveform
- Intra-abdominal pressure (IAP, bladder pressure)
- Intra-aortic balloon pump augmentation pressures
- Cardiac axis deviation, pulsus paradoxus, pulsus alternans, and electrical alternans on waveforms
- QRS interval adjustment and QTc interval adjustment for simulating various waveform morphologies
- ST-segment elevation/depression and T-wave elevation/depression on all 12 ECG leads
- Defibrillation, cardioversion, and transcutaneous pacing
- Fetal heart rate (FHR), fetal heart rate variability, and uterine contractions (frequency and duration)
Also, Infirmary Integrated simulates the following cardiac rhythms with waveforms and corresponding vital signs for scenario management:
- Asystole
- Atrial Fibrillation
- Atrial Flutter
- AV Block, 1st Degree
- AV Block, 3rd Degree
- AV Block, Mobitz II
- AV Block, Wenckebach
- Bundle Branch Block
- CPR Artifact
- Idioventricular
- Junctional
- Pulseless Electrical Activity
- Sick Sinus Syndrome
- Sinus Arrhythmia
- Sinus Rhythm
- Sinus Rhythm with Arrest (Sinoatrial Arrest)
- Sinus Rhythm with Bigeminy
- Sinus Rhythm with Trigeminy
- Sinus Rhythm with PACs
- Sinus Rhythm with PJCs
- Sinus Rhythm with PVCs Multifocal
- Sinus Rhythm with PVCs Unifocal
- Supraventricular Tachycardia
- Ventricular Fibrillation Coarse
- Ventricular Fibrillation Fine
- Ventricular Standstill
- Ventricular Tachycardia Monomorphic Pulsed
- Ventricular Tachycardia Monomorphic Pulseless
- Ventricular Tachycardia Polymorphic
Infirmary Integrated also simulates the following respiratory rhythms:
- Agonal
- Apnea
- Apneustic
- Ataxic
- Biot
- Cheyne-Stokes
- Regular
Infirmary Integrated also simulates the following fetal heart rhythms:
- Baseline (minimal variability)
- Accelerations
- Early Decelerations
- Late Decelerations
- Variable Decelerations
Infirmary Integrated also simulates features of an electronic health record (EHR) including:
- Navigating patients’ demographic information and clinical notes
- Navigating drug orders and doses due on an electronic Medication Administration Record (MAR)
Infirmary Integrated also supports full localization (translation) for the following languages:
- አማርኛ (Amharic)
- عربى (Arabic)
- 中文 (Chinese)
- Deutsche (German)
- English
- Español (Spanish)
- فارسی (Farsi)
- Français (French)
- עברית (Hebrew)
- हिंदी (Hindi)
- Italiano (Italian)
- Korean (한국어)
- Português (Portuguese)
- русский (Russian)
- Swahili (Kiswahili)
License
Infirmary Integrated is released under the Apache License 2.0 which can be viewed in Infirmary’s code repository.
Data Collection
Infirmary Integrated collects completely anonymized basic usage data to help guide development decisions. You can view a complete breakdown of the data collected when running Infirmary Integrated.
Development Team
 | Lead Developer (Full Stack) A professional registered nurse and a hobbyist programmer, I created Infirmary Integrated to combine my two passions: providing quality nursing care and advancing technology. By using technology to enrich educational experiences, I believe nurses and doctors can better learn to care for ill patients and improve patient outcomes. |
About Development
Infirmary Integrated was designed with inspiration and knowledge gained from a variety of sources, including:
- Life In The Fast Lane: Critical Care Compendium and ECG Library were used as technical references and inspiration for ECG, cardiac rhythm, and pulsatile rhythm modeling.
- The following resources were used as technical references and inspiration for cardiotocography (external fetal monitoring) modeling:
And print sources utilized as references in physiologic modeling include:
Alastruey, J., Charlton, P. H., Bikia, V., Paliakaite, B., Hametner, B., Bruno, R. M., Mulder, M. P., Vennin, S., Piskin, S., Khir, A. W., Guala, A., Mayer, C. C., Mynard, J., Hughes, A. D., Segers, P., & Westerhof, B. E. (2023). Arterial pulse wave modeling and analysis for vascular-age studies: A review from VascAgeNet. American Journal of Physiology-Heart and Circulatory Physiology, 325(1), H1–H29. https://doi.org/10.1152/ajpheart.00705.2022
Esper, S. A., & Pinsky, M. R. (2014). Arterial waveform analysis. Best Practice & Research Clinical Anaesthesiology, 28(4), 363–380. https://doi.org/10.1016/j.bpa.2014.08.002
Mark, J. B. (1998). Atlas of Cardiovascular Modeling. Churchill Livingstone.
Software development for Infirmary Integrated was undertaken with other free and/or open source tools that have been integral to its development. To name a few:
